408 Application & Permit 1973 No..561..
THE COMMONWEALTH OF MASSACHUSETTS
OARD OF HEALTH
c�Q OF
.Appliratinn fur Disposal arks Ginsirurynn 'lrrrnit
F Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
FETES
i 6 ,1 Ranin CP/
,/�1(s Lercalmn or Lot No
�.IG(�,O�i�ss .... t
Address
Installer Address
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacity gallons Length Width Diameter Depth
Disposal Trench—No. Width Total Length Total leaching area sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box ( )
Percolation Test Results
Test Pit No. 1
Test Pit No. 2
Dosing tank ( )
Performed by Date
uinutes per inch Depth of Test Pit Depth to ground water
uinutes per inch Depth of Test Pit Depth to ground water
Description of Soil
Nature of Repairs or Alterations—Answer when applicable..Aoki" kid...?•/
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued,t/y the board of ealth.
Signed
{. .. ...%...Q�tfYa.-.rti_rti
Application Approved By j i°'t- Y.-- -.- -Application Disapproved for the following reasons'
]ate
Permit No –SO./
Issued
D
JD.73ate
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
tale.4he ?Jett-air
Trrtifiratr of at liana
THIS 1510 CERTIFL,That the Individual Sewage Disposal System constructed ( ) or Repaired Gk.(
by .71AA sit rtsforeW•
Installer
at. 5.11..k....241-flattlenarait
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. -
DATE Inspector444 al4}1
No...34 I
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF /j40•111414
FEE 47...12 g
Bispasal nritioe,,,ntiiiyitttion fitnnit
Permission is hereby granted_ "IAA ial""
to Construct ( ) or Repair ( an Individual Sewage Disposal System
at No C4
Street
as shown on the application for Disposal Works Construction Pe t No Dated ,tiitt.
• .‘4../1 7-1
Gard Of Ilea Itlf
DATE
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS